Bonus

12 month Maintenance and Product Liability period from issue of Occupancy Certificate

First Name:

Last Name:

Phone:

Fax:

Email:

Street Address:

Suburb:

Post Code:

State:

Office Address same as Postal Address:

Office Street Address:

Office Suburb:

Office Post code:

Office State:

Name of other parties (List names of clients, principals, fiananciers & subcontactors):

Insurance Start Date:

Insurance End Date:

Description of business activities:

Please type N/A, if not applicable

Previous experience:

Details of ALL claims in last 3 years::

Please type N/A, if not applicable

Limit for any one contract ($/per project):

Limit of liability protection required:

Activities undertaken by you:

Projects valued over $2,000,000
Civil works not associated with a building contract
Excavation more than 2m in depth
Works under, over in, or near water (within 10m)
Work above the 25th parallel
Work involving special hazards
Work with asbestos
Work involving piling, shoring or proppingPlease tick those that are applicable to you

Help us help you by answering this survey question: What type of roof do you have?:

Prior to entering into a contract of general insurance you have a duty to disclose certain information. You have the same duty to disclose prior to renewing, extending or varying a general insurance contract. When answering the questions you must be honest and you have a duty under law to tell us anything known to you. You, and of which a reasonable person in the known circumstances would include in answer to the questions. We use the answers in deciding whether to insure you and on what terms. If you do not answer the questions in this way, we may reduce or refuse to pay a claim, or cancel the policy. If you answer questions fraudulently, we may refuse to pay a claim and treat the policy as never have been valid.

Declaration:

I / We confirm we have read the Duty of Disclosure included in this application form and confirm the answers are true correct and that no information has been withheld which may affect the decision to accept this application or the terms and conditions.